Temporomandibular (TM) Disorders

Topic Overview

What are temporomandibular disorders?

Temporomandibular (TM) disorders is the name given to several problems with jaw movement and pain in and around the jaw joints .

You may also hear TM disorders called TMJ, TMD, or TM problems.

The jaw joints, or temporomandibular (TM) joints, connect the lower jawbone (mandible) to the skull. These flexible joints are used more than any other joint in the body. They allow the jaw to open and close for talking, chewing, swallowing, yawning, and other movements.

Many people have problems with jaw movement and pain in and around the jaw joints at some time during their lives. These joint and muscle problems are complex. So finding the right diagnosis and treatment of TM disorders may take some time.

What are the symptoms?

TM disorders can affect the jaw and jaw joint as well as muscles in the face, shoulder, head, and neck. Common symptoms include joint pain, muscle pain, headaches, joint sounds, trouble with fully opening the mouth, and jaw locking.

In most cases, symptoms of TM disorders are mild. They tend to come and go without getting worse and usually go away without a doctor's care. About 65% to 95% of people who see a doctor when they first have symptoms will get better no matter what type of treatment they get.¹

Some people who have TM disorders develop long-lasting (chronic) symptoms. Any chronic pain or difficulty moving the jaw may affect talking, eating, and swallowing. This may affect a person's overall sense of well-being.

See a picture of areas often affected by TM disorder pain .

What causes TM disorders?

The most common cause of TM disorder symptoms is muscle tension, often triggered by stress. When you are under stress, you may be in the habit of clenching or grinding your teeth. These habits can tire the jaw muscles and lead to a cycle of muscle spasm, tissue damage, pain, sore muscles, and more spasm.

TM disorders can start when there is a problem with the joint itself, such as:

• An injury to the joint or the tissues around it.
• Problems with how the joint is shaped.
• Joint diseases, such as osteoarthritis or rheumatoid arthritis.
• The articular disc that cushions the joint shifts out of place.

How is a TM disorder diagnosed?

Although there is no one way to identify a TM disorder, your doctor can most likely check your condition with a physical exam and by asking questions about your past health. In some cases, an X-ray, CT scan, or MRI is also used to check for bone or soft tissue problems related to symptoms of TM disorder.

How is it treated?

TM disorder symptoms usually go away without treatment. Simple home treatment can often relieve mild jaw pain. There are things you can do at first to reduce pain.

• Rest your jaw joint.
• Use medicines for a short time, to reduce swelling or relax muscles.
• Put either an ice pack or a warm, moist cloth on your jaw for 15 minutes several times a day if it makes your jaw feel better. Or you can switch back and forth between moist heat and cold. Gently open and close your mouth while you use the ice pack or heat. But don't use heat if your jaw is swollen. Use only ice until the swelling is gone.
• Eat soft foods, and avoid chewy foods and chewing gum.

Getting physical therapy and learning ways to reduce stress may also help to reduce pain and TM joint problems. Continue to use some of these methods over time to prevent and manage symptoms that might come back. If your pain is chronic or severe or is caused by problems with how the joint is shaped, your doctor may recommend other treatments.

Splints, also called biteplates, are a common dental treatment for TM disorders. Splints are usually clear pieces of plastic that fit between the upper and lower teeth. They help reduce grinding and clenching. Splints are used for a short time so that they do not cause permanent changes in the teeth or jaw.

Before you try treatments such as surgery or reshaping or shaving down the teeth, think it over. These treatments cannot be reversed and can even damage the TM joint.

For most people, surgery is not used to treat TM disorders. Surgery has few benefits, and there is the chance of causing more serious problems. You and your doctor can carefully weigh a decision to have surgery. Talking with another doctor to get a second opinion can also help you make your decision.

Chronic pain can lead to depression, anxiety, and other problems. If you have chronic pain, talk to your doctor about medicine and mental exercises to manage the pain. Give special attention to treating any related anxiety or depression.

Frequently Asked Questions

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	Should I have surgery for temporomandibular disorder?

Cause

Temporomandibular (TM) disorders can result from a single cause or, more commonly, a combination of causes.

The main causes of TM disorders include:

• Muscle tension (tightness) and spasm. Muscle tension in the jaw, face, head, neck, and shoulders may make your jaw feel achy, stiff, and painful, especially when moving your jaw. Muscle tension may be:
  • Caused by stress and anxiety and by stress-related habits, such as daytime or nighttime clenching or grinding your teeth (bruxism), excessive gum chewing, or nail biting.
  • A response to structural problems within the joint or injury to the joint.
• Problems in the internal structure of the joint, such as:
  • Displacement of the disc that cushions the joint.
  • Degenerative disease, such as osteoarthritis or rheumatoid arthritis, which causes inflammation and destruction of the joint tissues.
  • Scar tissue or bone damage caused by accidental injury or a blow to the jaw.
  • Disease, such as a tumor, or structural problems present at birth (congenital).

In most cases, it is not possible to fully determine the causes of TM disorder symptoms.¹ In many cases, TM disorder symptoms appear to be caused by both muscle tension (tightness) and joint dysfunction. It is not always clear which came first. For example, osteoarthritis can cause changes in the joint, which may then bring on muscle spasms. Conversely, muscle spasms over time hinder jaw function and can eventually cause osteoarthritis in the jaw joint. A similar relationship appears to exist between muscle tension and disc displacement within the joint.

Orthodontic treatment and malocclusion do not trigger TM disorders or make them worse.

When jaw joint problems are caused by diseases such as rheumatoid arthritis, treatment for the underlying condition is important. Many other conditions cause symptoms similar to those of TM disorders, such as migraine headaches and infections.

Symptoms

Symptoms of temporomandibular (TM) disorders are usually mild and temporary and typically do not get worse with time. Common symptoms include:

• Joint pain when the jaw is moving, as when opening the mouth widely, chewing, or yawning. Such pain can develop:
  • Usually on one side of the jaw, but it can develop on both sides.
  • Either gradually or suddenly, as when biting down on something hard or following a blow to the jaw.
• Muscle pain or tenderness in the face, ear, head, neck, or shoulders.
• Headaches. In children with TM disorders, these are often related to grinding the teeth (bruxism).
• Clicking, popping, cracking, or grating that is painful and occurs when opening the jaw (may be a sign of disc displacement). Clicking or popping noises without pain are common and do not require treatment.
• The jaw locking in an open or closed position or not opening wide (disc displacement). If the jaw locks for more than a few moments, a muscle spasm usually follows.

See a picture of areas typically affected by TM disorder pain .

Sometimes pain around the ear, with pressure or ringing in the ears (tinnitus), develops with TM disorders. Some people with these symptoms report that they also have hearing loss, although test results show that their hearing is normal.

Symptoms often go away on their own, and they may recur over time without getting much better or worse. Occasional discomfort in the jaw joint or chewing muscles is quite common and usually is not a cause for concern.

Chronic pain

Some people with TM disorders have facial or jaw pain that lasts a long time (chronic). These people may try several treatment methods and have little improvement. While treatment can appear successful to a doctor, pain lingers. This may be due to the lasting psychological and biological impact of chronic pain, which can lead to or intensify depression, anxiety, a sense of helplessness, and biochemical changes in the body that perpetuate pain.

What Happens

The course of temporomandibular (TM) disorders caused by muscle tension varies depending on the cause of the muscle tension.

• If muscle tension is related to a one-time overuse injury (such as holding your mouth open for a long time during a dental exam), the pain and discomfort may go away without treatment. Similarly, about 65% to 95% of people who see a health professional about TM disorder symptoms for the first time will get better regardless of the treatment.¹
• If there is long-lasting (chronic) muscle tension due to stress, anxiety, an injury or blow to the jaw, or habits like grinding the teeth during sleep, treatment (including changing certain habits) may relieve pain and discomfort. If chronic muscle tension is not treated, it may gradually cause changes in the joint structure or osteoarthritis.

TM disorders caused by problems in the structure of the jaw joint may:

• Respond well to nonsurgical treatment, if treated early.
• Get worse, if not treated. Long-term consequences include injury to the disc or other tissues in the joint, arthritis, or chronic pain.

Chronic pain

In some cases, TM disorders can be extremely painful and disabling and last a long time. Such chronic pain can affect a person's overall quality of life by increasing stress, making it difficult to perform a job, and interfering with personal life. Depression and anxiety are a common result of chronic pain. In these cases, it is especially important to seek treatment for TM disorder pain and for related depression and anxiety.

What Increases Your Risk

Risk factors for temporomandibular (TM) disorders include:

• Stress and anxiety, which can cause facial and jaw muscle tension.
• Repetitive habits, such as grinding your teeth (bruxism), clenching your teeth, excessive gum chewing, eating hard or chewy foods, and nail biting.
• Habits that can cause muscle tension, such as sleeping on one side of your face or with your mouth open, opening your mouth wide when yawning or singing, or holding your head up by cradling your jaw in your hand.
• Injury to the jaw or head. TM disorders can result from a direct blow to the jaw, chin, or head; whiplash to the head or neck; overstretching the jaw during dental work or surgery; or other injuries that may lead to joint damage or muscle tension.
• Age and sex. TM disorders primarily affect people between the ages of 20 and 50. While some studies show that men and women are equally affected, others identify women in their childbearing years as reporting symptoms at the highest rates.²

In the past, malocclusion and orthodontics were thought to cause or contribute to TM disorders. Similarly, orthodontics have been used to treat TM disorders. Despite ongoing controversy, current research suggests that:

• Malocclusion does not cause TM disorders.¹
• Orthodontic treatment does not cause or cure TM disorders.²

When To Call a Doctor

Call your dentist or other health professional immediately if you have had an injury to your jaw or face and:

• Your jaw is very painful.
• Your jaw is locked open or shut, or you are unable to move your jaw easily or smoothly (a sign of disc displacement, dislocation, or fracture).
• Your jaw appears to be deformed or swollen.
• There is swelling in the sides of your face.
• Your teeth no longer fit together normally when biting down (malocclusion).
• A severe headache or neck ache strikes suddenly, without apparent cause, or is different from previous headaches.

Call your dentist or other health professional if you:

• Have pain when moving your jaw (biting, chewing, swallowing, talking, or yawning) that is not getting better after 2 weeks of home treatment.
• Have had jaw pain for a long time (chronic).
• Have anxiety, stress, or work-related problems caused by your jaw discomfort and pain.
• Continue to have symptoms (such as pain with clicking or cracking sounds or your jaw locks) after 2 weeks of home treatment.
• Notice a change in the way your teeth fit together when you close your mouth.

Watchful Waiting

Mild symptoms of TM disorders usually respond to home treatment. Try home treatment for at least 2 to 4 weeks before considering other types of treatment. For most people, TM disorder discomfort will eventually go away whether it is treated or not. About 65% to 95% of people who see a health professional for initial TM disorder symptoms will get better regardless of the treatment prescribed.¹

Because few health and dental insurance plans cover TM disorder treatment, home treatment is usually a wise first step.

Who To See

Your treatment for temporomandibular (TM) disorder may involve several different health professionals.

Initial evaluation can be done by a:

• Dentist.
• Family medicine doctor or other primary care health professional.

Further diagnosis and treatment may be done by a:

• Dentist who specializes in treating TM disorders.
• Physical therapist.
• Facial pain expert.
• Oral and maxillofacial surgeon.

Additional treatment may be provided by:

• A mental health professional for stress management.
• A specialist in a chronic pain clinic (often located in a dental school or hospital setting).
• A physical therapist.
• A registered dietitian or nutritionist, particularly if you are unable to eat solid foods.

If a health professional suggests that you try a treatment that might make permanent changes to your jaw, confirm this recommendation with a second opinion.

Most health and dental insurance plans do not cover TM disorder diagnosis and treatment. Because some tests and treatments are quite expensive, you may want to verify your insurance coverage before incurring expenses.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

Currently there is no widely accepted standard test for identifying the cause of temporomandibular (TM) disorders. But your dentist or primary care doctor will most likely be able to accurately diagnose your condition with information from a medical history and physical exam.

Most TM disorders are caused or made worse by muscle tension (tightness). Expect your health professional to suggest treatment that does not involve surgery or permanent changes to the jaw (conservative treatment) to relieve your jaw pain, muscle tension, and TM joint problems.

If you have sudden pain after a facial or jaw injury, your health professional is likely to order some type of imaging test, such as an X-ray, a CT scan, or magnetic resonance imaging (MRI).

If conservative treatment has not worked

If conservative treatment has not worked and your jaw is locking in place (a sign of disc displacement), your pain is severe or chronic, or you have other medical problems, such as rheumatoid arthritis, other tests may be needed. These tests are usually done only if knowing their results could change your recommended treatment plan.

If your symptoms persist after the first period of treatment, your health professional may begin to look for problems in the jaw joint structure. Additional tests may include:

• X-ray. This test can confirm whether the bones are worn away, broken, or disfigured. If disc displacement is suspected, X-rays may be helpful to show the size of the joint space. A narrow joint space can be a sign that the disc is affected.
• Magnetic resonance imaging (MRI). A view of the soft tissues (ligaments, muscles, and articular disc) is useful in showing disc displacement or damage. Although expensive, MRI is considered the most effective imaging technique for assessing TM disorders that may involve disc problems.

Treatment Overview

The goal of treatment for temporomandibular (TM) disorders is to relieve pain in the jaw and restore normal jaw movement and function. Several treatment approaches are effective. Often, simple home treatment measures can successfully relieve jaw pain without medical or dental treatment. For chronic, muscle-related TM disorders, standard medical care can include muscle relaxation measures, biofeedback, stress management, or cognitive-behavioral therapy.

The National Institutes of Health (NIH) recommends conservative, noninvasive treatment measures for TM disorders. For first-time treatment of TM disorder symptoms, the NIH recommends avoiding invasive or irreversible procedures, such as surgery or dental/orthodontic work.²

The most common dental treatment for TM disorders is using splints or biteplates for a short period of time. Splints-called occlusal splints-are usually clear, plastic appliances that fit between the upper and lower teeth. They help reduce grinding and clenching (bruxism) and, in turn, can relieve muscle tension and pain. This may allow a displaced disc to return to its normal position. Splints are used over short periods of time so that they do not cause permanent changes in the teeth or jaw.

Temporarily avoid dental work (such as crowns, bridges, or shaving down the teeth) and orthodontic treatments involving permanent changes to the jaw. At best, these measures may not work any better than conservative treatments. At worst, they can cause irreversible damage. If your health professional recommends surgery or other treatment that involves permanent changes, always get a second opinion before starting treatment.

Should I have surgery for a temporomandibular disorder?

See the Home Treatment, Other Treatment, and Surgery sections of this topic for specific treatment options.

What To Think About

Often, structural problems in the jaw, such as disc displacement, can be improved with conservative (nonsurgical) treatment, especially when they are treated early.

In the past, teeth not fitting together properly (malocclusion) was considered to be a cause of TM disorders, and braces (orthodontics) were used to treat them. Currently, health professionals generally agree that a malocclusion is unlikely to be the cause of a TM disorder.¹ Similarly, orthodontics are no longer a recommended treatment for TM disorders.

Most health and dental insurance plans do not cover TM disorders. Check with your insurance provider to confirm whether you are covered before incurring medical or dental expenses related to diagnosis or treatment.

Prevention

To prevent temporomandibular (TM) disorders, try to reduce muscle tension in your jaw. You can reduce muscle tension with these steps:

• Relax. If you have a lot of stress and anxiety in your life, try relaxation techniques. See the topic Stress Management.
• Learn to recognize when you are clenching your teeth. Practice keeping your teeth apart, bringing them together only when swallowing or eating. When driving, avoid clenching the wheel with both hands because often your teeth will be clenched as well.
• Do not overuse and stress your jaw muscles. Avoid constantly chewing gum, biting your nails, resting your chin on your hand, or cradling the telephone receiver between your shoulder and jaw.
• Change your diet. Eat softer foods, and use both sides of your mouth to chew your food. Avoid hard or chewy foods, such as popcorn, apples, carrots, taffy, hard breads, and bagels.
• Maintain good posture. Poor posture may disturb the natural alignment of your facial bones and muscles, causing pain.

In the past, various procedures such as dental restoration and orthodontic treatment were used to prevent joint sounds from developing into TM disorders. Such "preventive" measures are not only unnecessary but also potentially damaging to a joint that may never become painful on its own.

See the Home Treatment section of this topic for other steps to prevent or reduce muscle tension in your jaw.

Home Treatment

If your temporomandibular (TM) disorder symptoms are mild, try home treatment for at least 2 weeks. If your symptoms get worse during this time, call your health professional or dentist.

Home treatment involves reducing your stress, resting your jaw (by eating only soft or pureed foods), taking steps to reduce pain, and exercising your jaw.

To help relieve pain and restore jaw function:

• Put either an ice pack or a warm, moist cloth on your jaw for 15 minutes several times a day if it makes your jaw feel better. Or you can switch back and forth between moist heat and cold. Gently open and close your mouth while you use the ice pack or heat. But don't use heat if your jaw is swollen. Use only ice until the swelling is gone.
• Change your diet to decrease jaw strain.
• Modify your jaw movements to keep your jaw muscles relaxed.
• Do jaw exercises as prescribed by your doctor or physical therapist.
• Try comfort measures such as moist heat, ice, or nonsteroidal anti-inflammatory drugs (NSAIDs).
• Reduce stress. Many people tend to clench or tighten their muscles when they are under stress of any kind.
• Change your body mechanics, such as by using good posture for sitting and standing.

If you have been diagnosed with a TM disorder, these home treatment measures will optimize the treatments prescribed by your health professional or dentist, such as a splint therapy or physical therapy.

Medications

You can use medication to relieve the pain of a temporomandibular (TM) disorder. Short-term use of nonsteroidal anti-inflammatory drugs (NSAIDs), narcotics, muscle relaxants, or antidepressant medications can relieve or reduce inflammation, control pain, and relax the jaw muscles.

Medication Choices

• Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to treat inflammation and pain. These are the most commonly used medications for TM disorders.
• Narcotic pain relievers (such as acetaminophen with codeine or hydrocodone) are used in some cases of acute, severe pain. Because narcotics are addictive, they are usually not taken long term.
• Muscle relaxants, such as diazepam (Valium) or cyclobenzaprine (Flexeril), are used in some cases of acute pain or prolonged muscle spasm. Because they are addictive, sedating, and can cause depression or make it worse, muscle relaxants should be taken at the lowest possible dose and are usually not used long term.
• Low doses of tricyclic antidepressants, such as amitriptyline, can effectively relieve chronic pain and make treatment more successful, but the effects seem to decrease over time.³ These medications have also been helpful for improving disrupted sleep patterns, which can cause bruxism.

What To Think About

Nonsteroidal anti-inflammatory drugs (NSAIDs) do not cure TM disorders, but they may reduce pain and inflammation, which allows you to do prescribed jaw exercises that can start the healing process. NSAIDs may be prescribed on a regular basis for 1 to 2 weeks to help reduce inflammation even though the pain has subsided.

Your doctor may prescribe an antidepressant, not necessarily because you suffer from depression but to help treat chronic pain or nighttime bruxism.

Surgery

Surgery is rarely used to treat temporomandibular (TM) disorders. Surgical treatment does not guarantee a cure and can further damage the temporomandibular joint. Because most TM disorders can be treated nonsurgically, most health professionals believe that surgery should be the last option tried and should be avoided if possible.

Surgery may be a treatment option for you if both of the following apply:

• Other treatments have failed, and chronic jaw pain and dysfunction have become disabling.
• There are specific, severe structural problems in the jaw joint. These include scar tissue in the joint area, problems with bone alignment, broken or degenerated bones, and occasionally disc displacement or perforation.

The goals of surgery for temporomandibular (TM) disorders are to:

• Relieve pain in the jaw joint.
• Correct any structural problems.
• Restore normal jaw function.

Should I have surgery for a temporomandibular disorder?

Surgery Choices

• Arthrocentesis. This is not a true surgery, since there is no incision, but it is an invasive procedure performed by an oral and maxillofacial surgeon. In one study, arthrocentesis to wash out the joint area (lavage) was successful for 94% of people with severe closed lock of the temporomandibular joint.⁴

Surgery may include:

• Arthroscopic procedures, including washing out the joint area (lavage), cutting or removing scar tissue that is blocking joint movement (lysis), cutting tissue that has shortened and is impeding joint function, or shaving part of the disc.
• Open joint arthroplasty, used for disabling joint problems that aren't easily reached or viewed arthroscopically.

Another type of surgery, called total joint replacement, is rarely done. It has sometimes resulted in permanent jaw damage. Total joint replacement replaces the jaw joint with artificial parts. In some cases the artificial parts have not worked correctly or have broken. The available technology for this surgery is still considered to be experimental and risky.

What To Think About

Further pain complications or joint dysfunction can result from temporomandibular joint surgery.

Researchers have found that surgically repositioning a displaced disc is not necessary for treatment success. Rather, washing debris and removing any scar tissue from the joint area (lysis), whether using arthrocentesis or arthroscopy, is usually an effective treatment for a painfully locked jaw.⁴

Surgery is not necessary in most cases of disc displacement.⁵ Splint therapy (a dental treatment), jaw rest, and physical therapy, including moist heat and jaw exercises followed by an ice pack, can be very effective for treating this condition. If this and other nonsurgical treatment to relax the muscles are not successful, arthrocentesis may effectively treat your condition.

If you are thinking about surgery, get a second opinion on your condition and treatment.

Other Treatment

Many types of treatment can successfully relieve temporomandibular (TM) disorder symptoms. Different health professionals will suggest different treatments, any of which may work to relieve jaw and facial pain.

If a health professional recommends that you try a treatment that might make permanent changes to your jaw or teeth, get a second opinion.

Other Treatment Choices

Depending on your condition, one of the following choices may be more effective than another. Safe options for treatment of TM disorder include:

• Some dental treatments, including splint therapy to relieve pressure on the TM joint.
• Physical therapy.
• Behavioral counseling.
• Biofeedback.
• Trigger point management.

Complementary medicine

Treatments considered safe and effective for some people include:

• Hypnosis.
• Acupuncture.

What To Think About

Many different types of treatment for temporomandibular (TM) disorders have potential for successfully relieving your condition. If your problem is linked to muscle tension, any treatment that helps you relax your jaw muscles with no adverse effects is likely to be helpful. Different treatments work for different people.

Treatments vary greatly in effectiveness, safety, and cost.

Other Places To Get Help

Organizations

Related Information

• Complementary Medicine
• Headaches
• Malocclusion and Orthodontics
• Stress Management

References

Citations

1. Eriksson PO, Zafar H (2007). Cervico-cranio-mandibular disorders. In RE Rakel, ET Bope, eds., Conn's Current Therapy 2007, pp. 1143-1148. Philadelphia: Saunders Elsevier.

2. Management of Temporomandibular Disorders. NIH Technology Assessment Statement (1996 April 29-May 1). Available online: http://text.nlm.nih.gov/nih/ta/www/018txt.html.

3. Plesh O, et al. (2000). Amitriptyline treatment of chronic pain in patients with temporomandibular disorders. Journal of Oral Rehabilitation, 27: 834-841.

4. Barkin S, Weinberg S (2000). Internal derangements of the temporomandibular joint: The role of arthroscopic surgery and arthrocentesis. Journal of the Canadian Dental Association, 66: 199-203.

5. Tucker MR, Ochs MW (2003). Management of temporomandibular disorders. In LJ Peterson et al., eds., Contemporary Oral and Maxillofacial Surgery, 4th ed., pp. 672-696. St. Louis: Mosby.

Other Works Consulted

• Dolwick MF (2001). Disc preservation surgery for the treatment of internal derangements of the temporomandibular joint. Journal of Oral and Maxillofacial Surgery, 59: 1047-1050.

• Indresano AT (2001). Surgical arthroscopy as the preferred treatment for internal derangements of the temporomandibular joint. Journal of Oral and Maxillofacial Surgery, 59: 308-312.

• White RD (2001). Arthroscopic lysis and lavage as the preferred treatment for internal derangement of the temporomandibular joint. Journal of Oral and Maxillofacial Surgery, 59: 313-316.

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